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UNIVERSITY of CALIFORNIA Los Angeles Understanding Key UNIVERSITY OF CALIFORNIA Los Angeles Understanding Key Players and Factors Involved in the Implementation of Physical Activity Push Strategies into Organizational Settings A dissertation submitted in partial satisfaction of the requirements for the degree Doctor of Public Health by Jammie Mack Hopkins 2012 © Copyright by Jammie Mack Hopkins 2012 ABSTRACT OF THE DISSERTATION Understanding Key Players and Factors Involved in the Implementation of Physical Activity Push Strategies into Organizational Settings by Jammie Mack Hopkins Doctor of Public Health University of California, Los Angeles, 2012 Professor Antronette K. Yancey, Chair Background: Integrating physical activity “active-by-default” or “push” strategies into the standard conduct of organizational settings is a promising approach to engage sedentary and overweight individuals in regular physical activity. However, organizations must navigate a number of factors to ensure these strategies remain sustainable over time and elicit favorable outcomes. This dissertation project examined the implementation process that human services worksites undertook while participating in the UCLA WORKING Project, a NIH-funded intervention promoting physical activity and healthy eating. Methods: Process evaluation notes obtained from worksites assigned to an active intervention group (N=24) were used to classify worksites according to four implementation success categories. Key informant interviews (n=13) with employee program champions and middle managers provided insight into roles and responsibilities, organizational dynamics, and factors associated with implementation success and failure. Individual clinical indicator and survey data ii collected on a voluntary sample of individuals (n=989) employed at participating worksites (N=40) were analyzed to determine any associations between the degree to which a worksite implemented strategies and changes in individual outcomes over a 6-month observation period. Organizational-level data collected from worksite representatives (n=4) were assessed to determine any associations between degree of implementation success and changes in organizational-level physical activity policies and practices over time. Results: Middle managers played a crucial role in translating and enforcing priorities for their worksites, supporting the efforts of program champions, participating in PA breaks, and advocating for the prioritization of PA strategies. Clear and explicit PA policies, leadership support, pre-existing wellness infrastructure, and the ability to negotiate heavy workloads were cited as factors most strongly associated with successful implementation. Worksites that most successfully implemented the PA strategies had greater improvements over time in employees’ BMI, systolic blood pressure, weight, and perception of co-workers initiating PA breaks than less successful worksites. Conclusion: These findings suggest that implementation success may be linked to favorable outcomes, and that the WORKING Project may have successfully elicited favorable changes among employees with the poorest outcomes and highest risk of obesity and its related co- morbidities. Lessons learned from this project can inform future physical activity implementation and dissemination efforts within organizational settings. iii The dissertation of Jammie Mack Hopkins is been approved. William McCarthy Hector Rodriguez Kynna Wright Antronette K. Yancey, Committee Chair University of California, Los Angeles 2012 iv DEDICATION I dedicate this dissertation to my everlasting “legacy of love.” At the foundation of this legacy reside my mother, Annie Mae Hopkins (RIP), and my father, Mack Q. Hopkins Jr. Thank you both for instilling in me a sense of purpose and confidence from the beginning, supporting my dreams and aspirations, and refusing to let me fall short of my true potential. I love you with all of my heart, and I intend to make you proud for the rest of my life. To my brothers, my beautiful sister, cousins, and extended family: Thank you for all of the lessons you’ve taught me over the years. Without them I would not be the man I am today. I hope that my journey will continue to inspire you as much as you have inspired me. To my amazing nephews, nieces, and future children: Let this dissertation serve as proof that you can do anything you set your mind to! I may be the first, but I will certainly not be the last to cross this academic threshold. I encourage you to push against the grain, have the audacity to be excellent, and go for yours! It may take everything you’ve got, but you’ve got what it takes! v Table of Contents CHAPTER 1: Introduction and Background .............................................................................1 CHAPTER 2: Organizational Profile – LA County Department of Public Health ..............13 CHAPTER 3: Description of the “Innovation”: UCLA WORKING Project........................25 CHAPTER 4: Addressing the Problem .....................................................................................35 CHAPTER 5: Methods................................................................................................................51 CHAPTER 6: Results from Process Evaluation and Key Informant Interviews..................75 CHAPTER 7: Quantitative Results from Individual and Organizational Assessments.......99 CHAPTER 8: Discussion and Conclusion...............................................................................120 TABLES......................................................................................................................................133 APPENDICES............................................................................................................................153 Appendix A: Integrating Physical Activity into Health and Human Services Organizations (Full Conceptual Model)..............................................................................................................153 Appendix B: Environmental Audit Form ....................................................................................154 Appendix C: Site Visit Form .......................................................................................................156 Appendix D: Intervention Summary............................................................................................159 Appendix E: Key Informant Recruitment E-mail........................................................................162 Appendix F: Key Informant Interview Fact Sheet.......................................................................164 Appendix G: Key Informant Interview Consent Form................................................................167 Appendix H: Key Informant Interview Guide for Program Champions .....................................170 Appendix I: Key Informant Interview Guide for Middle Managers ...........................................173 Appendix J: Key Informant Interview Codebook........................................................................176 REFERENCES...........................................................................................................................179 vi LIST OF FIGURES Figure 4.1: Integrating Physical Activity Breaks into Health and Human Services 42 Organizations (Conceptual Model) Figure 4.2: Key Relationships to be explored in dissertation 48 vii LIST OF TABLES Table 3.1: WORKING intervention policies and practices 27 Table 5.1: Breakdown of enrolled WORKING sites by type 54 Table 5.2: Demographics for Pilot Study Worksites 133 Table 5.3: Demographics for Full-scale intervention trial worksites 134 Table 5.4: Criteria for determining implementation success 59 Table 5.5: Implementation Success Categories 60 Table 5.6: Domains and topics covered in the key informant interview guides 64 Table 5.7: Breakdown of individual participants by study phase and intervention group 67 assignment Table 5.8: Clinical indicators of interest 70 Table 5.9: Individual variables of interest from individual participant survey 71 Table 5.10: Organizational-level variables of interest from Worksite Wellness 71 Assessment Table 6.1: Key Informant Descriptive Information 76 Table 6.2: Implementation success categories and characteristics 78 Table 6.3: Managers’ role in agenda setting and innovation implementation 79 Table 6.4: Middle manager engagement in PA implementation 85 Table 6.5: Perceived outcomes resulting from implementing PA strategies on paid time 96 Table 7.1: Descriptive and demographic statistics by study phase and full merged 135 sample Table 7.2: Descriptive and demographic statistics by implementation success category 136 Table 7.3: Descriptive and demographic statistics by intervention study group 137 Table 7.4: Did implementation success influence changes in BMI over time? 138 Table 7.5: Did implementation success influence changes in diastolic BP over time? 139 viii Table 7.6: Did implementation success influence changes in Systolic BP over time? 140 Table 7.7: Did implementation success influence change in participants' weight (lbs) 141 over time? Table 7.8: Did implementation success influence change in participants' waist 142 circumference over time? Table 7.9: Did implementation success influence change in participants' 143 cardiorespiratory fitness (CF) over time? Table 7.10: List of co-worker social support questions 110 Table 7.11: Did implementation success influence change in participants’ perception of 144 co-workers complimenting PA over time? Table 7.12: Did
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